Archive for September, 2009

Dirty Rotten Scoundrel, M.D. Apparently that’s me, and for the most part pretty much all of my physician colleagues if you listen to the President, Members of Congress, and various and sundry pundits from all sides of the political spectrum. There is a over-riding assumption of ill-will and mal-intent when the public is asked about doctors and how doctors behave in our modern medical system. Everyone talks about bad behavior, how doctors are at the root of many (most?) of the “problems with healthcare” in the United States, looking out for themselves first and always, rather than looking out for the best interests of their patients.

The stories told and the statements made are really quite amazing. Mind you now, there are really never any statistics offered that stand up to scrutiny, but the stories are just SO good and SO important that they just must be told. And told again. And again and again until through the sheer volume of the telling they just MUST be true. Like the recent statement by President Obama that Pediatricians would much rather remove a child’s tonsils than treat an infection with antibiotics because they, the pediatricians, would be paid so much more for doing the surgery. This one is pretty hurtful for countless reasons, none the least of which is the fact that neither the President nor any one of his minions is aware of the fact that pediatricians do not perform ANY surgeries, and that pediatricians do not garner any income whatsoever when an OTOLARYNGOLOGIST removes a child’s tonsils. Recent discussions in pediatric, infectious disease, and otolaryngology circles about the fact that childhood infections have RISEN in the decades in which tonsillectomies have declined, and that perhaps we are doing TOO FEW tonsillectomies now seem rather quaint and pointless in the face of such blatant political pandering. After all, how important can decreasing childhood infections be, really? We’ve got a healthcare system to save!

Is it really true? Do all doctors, or even most doctors, or even a measurable minority of doctors REALLY put their own economic well-being first? Is the first level of decision making in the office truly “which treatment will make me, the doctor, more money?” Could this possibly be the case? I really don’t see it.

In the U.S. becoming a doctor has always been a rather difficult task. American medicine has always been a true example of America as a meritocracy. Our doctors have traditionally been among the brightest of our citizens, students who excelled at every level of their education simply in order to qualify for the privilege of suffering through the pain of a medical education. Those who excelled in their medical school and post-graduate years started out with the best jobs in the nicest locations, or became the academicians who did the ground-breaking research that produced the dazzling array of medical advances that serve us today. A very large percentage of each town’s best and brightest became physicians.

Why? Why did so many of our brightest young people go into medicine? The men and women who are in the primes of their careers right now, did they do so in order to become rich? Was that a reasonable expectation, and were they told how to do this in school? Not to my memory.

Once upon a time, around the time that most of our doctors now in their prime were in grade school, the doctors in a town were held apart from other citizens–seen as different for accepting the calling of medicine. There was an assumption of goodwill born out of the experience that the doctor would be there to take care of you whenever you needed him. A high degree of respect and deference was granted those doctors, whether they were pediatricians or otolaryngologists or any other type of doctor. Physicians were well-off but they were not wealthy unless they were born to wealth. Being a physician was actually considered one way for a child of wealth to give back to the community. The wealthy in town were merchants or the owners of the factories. Doctors lived in nice houses in nice neighborhoods, but they did not live in the NICEST houses or THE neighborhoods. They often belonged to a country club, but not THE country club.

Doctors of that time, and indeed doctors up until relatively recently, had two very powerful incentives to work hard. In a free market where one is paid for doing work and for doing it well, the more hours you worked and the better you worked the more money you made. It has always seemed that it is easier to find the private practitioner, the doctor of any specialty who works for himself, when an emergency arises at 3:00 AM don’t you think? But more than that, the harder a doctor worked, the more he put aside his own time (and that of his family), the greater was the respect he earned in his community. Hard to value in dollar signs, but clearly valuable enough to create the archetypical American doctor, on call for his patient night and day. In return for devoting your talents to medicine, and in return for devoting years to the toils of becoming a doctor, and in return for placing your time at the disposal of your patients, your doctor recieved a very comfortable living as well as uncalculable respect.

With the exception of the 1980′s during which a small minority of doctors did, indeed, become truly wealthy from practicing some kind of medicine, doctors really did NOT, and do NOT get rich from their jobs. Some time in those 1980′s things started to change as more and more of our nation’s healthcare was purchased by the government or by insurance companies that took their cues from the government. All of a sudden the doctor was suspect, guilty of gaming the system at every turn. The medical record was no longer a tool to be used in the ongoing care of a patient but was now a legal document, the trap in a perpetual game of “gotcha” as third party payers and malpractice lawyers started to grind away at the reputation and goodwill of our doctors.

Why? Why did this happen? What am I NOT seeing in my offices and in the offices of every physician I have ever known that makes this so? The short answer is that I am not really missing anything at all. There really is no greater incidence of greed and graft on the part of physicians than ever in the past. It’s a ruse, a strawman. What is greater now is the benefit to be gained by individuals and institutions when all of that goodwill, that assumed respect accorded our doctors is slowly eroded, when doctors can then become a target that diverts attention from any number of more culpable groups.

Might this trend bear fruit? Might this, in fact, be the route that we take to controlling the healthcare economic problems in America? Aye, perhaps, but this is likely to be yet one more instance where we have the opportunity to see the genius of Heinlein, There Ain’t No Such Thing As A Free Lunch. Or perhaps this, from the Esteemed Physician in ‘Atlas Shrugged’: “Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and operating wards that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it…and still less safe, if he is the sort who doesn’t.”

You might miss me, the eye surgeon Dirty R. Scoundrel, M.D. and my colleagues Snide Lee Whiplash, M.D. the otolaryngologist, and Boris and Natasha Karloff, the husband and wife pediatricians. You will most certainly miss our children and the rest of the best and the brightest of their generation, none of whom are likely to be there to answer your sick call at 3:00 AM. They will most likely be home asleep in the NICEST house in THE neighborhood, tired after an evening at THE country club.

My wife Beth and I celebrated our 24th Wedding Anniversary this past weekend! How did we celebrate? We went on a date.

Our first “official” date took place when I was a first year medical student and Beth was a senior in college. There were six Williams grads in my class and we had planned a group trip to watch the Williams/Middlebury soccer and football games in Middlebury; I invited Beth to come along as part of the gang. As luck would have it the games turned out to be on the weekend just before our very first set of med school exams. One by one all of my classmates begged off and our casual group trip to Middlebury turned into a date. 27 years later we’re still dating.

In the early going it was pretty easy to keep right on dating after we got married. A quiet evening of board games over a glass of Riesling might be followed a few days later by a rousing night on the town in Burlington. We were college kids, accustomed to the rhythm and rhyme of the school schedule, with lots of common interests and pursuits. It was easy to be together and easy to get on complementary schedules.

Things got a little rougher when we left Burlington after my graduation. Internship and residency are just a grind, and Beth’s first job was third shift at the hospital. 70 and 80 hour work weeks with every third night on call meant some planning was going to be necessary, but we were still only responsible to and for each other. Pretty much every non-working waking hour was spent together. Well, every waking hour for at least one of us at a time, but we were together.

Then along came child number one. Biggest life change ever! Bigger than going to college, choosing a career, or even getting married. Whoa! Only one schedule on the board now, boy. Is he up ? Is he down? Our firstborn started walking at 7 months–a body without a brain. Where did he get to? Have you seen him? Like pretty much every new set of parents our entire lives revolved around the young “Heir”. We were too poor to afford a sitter, let alone childcare. Beth retired from active nursing to stay at home and we became Mom and Dad. Along came number two and the die seemed to be cast. No longer Beth and Darrell, we were parents now. Give me a kiss; I’ll see you after high school when the kids are off to college.

Have you ever seen that comic, the one where the husband dips the corner of his newspaper and the wife peers over her coffee as the last child skips out the door? “Hi, I’m John! Who are you?” I suppose nowadays it would be a Blackberry and a laptop between them, but you get the picture. So did we. Man, it seemed like everyone we knew with kids just off to college was getting divorced, especially the doctors. We missed each other, and we both saw that same, scary comic at the same time. Uh uh. Not us. This “Mom and Dad thing” might be the biggest part of our lives for, oh, 25 years or so, but some way, some how, we were going to find a little place for Beth and Darrell, too.

Thus was born “Date Night.”

Deeply in debt at the conclusion of residency we were too broke to do very much on those early Date Nights. Many’s the time we would have just enough to pay the babysitter. Our date on those nights might have been a single cup of coffee at Burger King, shared between us as we held hands across the table. But the ground rules had been set: other couples were welcome but no kids allowed, and pretty much nothing was more important in any given week than going out on Date Night.

The arrival of the third and final addition to our family coincided with a major move and gifted us with the Lutz sisters. Kerry and Krissie were our go-to sitters for years and years of Date Night. Our ballroom dancing phase (hug your spouse for an hour!) was followed by Ballet subscriptions, wine series, and countless restaurant “discoveries.” Date Night with babysitters made it through two Lutz graduations and and at least one wedding, long enough for us to head out and leave the three White progeny alone at home with their homework.

Until…well…we got kinda predictable I guess, and probably got a little cocky for a bit as well. There we were coming home a little on the early side from a new restaurant, giving ourselves a pat on the back for how well everything was going with the kids at home, when we turned into our EMPTY driveway. It seems son number one ,all of 15 years old and well-versed in the rhythm of Date Night, had taken his Mom’s car out for a drive with his buddies. We got a good chuckle at our own expense while we were awaiting their return, and Beth got quite a giggle watching me work up enough faux indignation to be convincing during the ensuing “discussion”.

Alas, thus ended Date Night as we had known it.

We tell every young couple about our Date Nights, especially where there’s a doctor involved. It’s really still amazing to the two of us how many marriages still fall apart when the kids are gone and it’s back to the original unit, the couple. You see, Date Night really hasn’t gone away; it’s just evolved into something new and something more of the same. Now it’s up together in the morning after the dogs get going and before any of the kids contemplate lift-off. Sharing breakfast and reading the newspaper to each other. A Sunday spent strolling the Hudson Food Festival listening to The Wiggles sing Woodstock (you had to be there). The same rules apply: other couples are welcome, but no kids allowed!

People talk about the importance of going 50/50 in a marriage. I think Beth is more on the mark, though. She talks about marriage as 100/100. Each spouse gives 100% of everything to everything every day. Each hand is “all in” every time you play when it comes to your marriage. Makes a ton of sense, doesn’t it? Date Night was just a small part of 100/100 for us, albeit one that made us smile and gave us lots of great stories, like the night our son called the close of our official Date Night program!

But not the end our our courtship! I almost forgot to tell you about our Honeymoon. What a blast THAT’S been. Next month we’re going to spend a long weekend in San Francisco. Maybe take a drive up to Napa for another visit to wine country.

The eminent philosopher Yogi Berra has captured the essential problem with the current fascination among our legislators and government bureaucrats with Electronic Medical Records (EMR or EHR). “In theory, there is no difference between practice and theory. In practice, there is.”

In my mind I have an image of the well-intentioned men and women who are developing the next generation of EMR. I see them as this generation’s equivalent of a pre-Foundation Bill Gates, or Steve Jobs before the black mock-turtle tee shirt. All nerdy and earnest, focused on the software solution to a problem they’ve read about. They peer out at the world beyond their screens, convinced of their ability to solve a problem they view from 30,000 feet, perhaps dreaming of becoming wealthy should they succeed.

I also have a picture in my head of the legions of un-elected bureaucrats in state capitols and in Washington who have latched onto this notion of EMR as the panacea, the magic solution to the American “Healthcare Crisis”. Equally earnest, white-paper educated omniscients convinced that a technical solution is all that is missing from the equation. They deal each day in the business of spending tax revenue and the legislative give and take that eventually results in a state or federal budget. Their time is spent with eyes glued to their laptops and their Blackberries, only seldom establishing eye contact with another of their kind ,and only then if absolutely necessary.

In THEORY this EMR thing is a no-brainer, isn’t it? Who wouldn’t think so? A true EMR is a system of record keeping for medical data in which all of the information is entered digitally and stored in hard drives instead of paper charts. Every time a patient is seen by a doctor or a nurse-practitioner his entire medical record is there for the viewing. No lost pages. No missing data. No struggling with the abysmal handwriting of the busy specialist who saw him for an emergency at 4:00 AM. What’s not to like about that?

In THEORY a universally applied EMR should also create some economic advantages in our healthcare system as well. We would theoretically need fewer billing assistants since all of the charge information would flow automatically from the medical record to the billing system, and from there straight to the payer. There would be few, if any billing errors since the coding and reporting requirements for each insurance company (or the federal government) would be built into the software. Since all of the information about medical outcomes would now be instantly available we would now be able to evaluate competing treatments and determine objectively which ones work and are therefore worth their cost to provide.

Unfortunately it turns out that Yogi Berra is not only a philosopher, but in this instance he is also a genius. You see, in PRACTICE all of this theory falls apart because of a rather messy and unpredictable variable in the system that the EMR designers and the all-knowing bureaucrats just can’t remove from their programs or their systems: all of the patients and all of the healthcare workers are PEOPLE. People who are sick and become patients. People who don’t want to be sick and try not to be patients. People who come to work fresh and adequately caffeinated, and people who are really patients that particular day and don’t know it, spilling their Starbucks on the keyboard.

Computers and the software that runs computers reduce work and increase efficiency in their optimum usage. They enhance the experience of all who encounter them “in the wild” when they fulfill their potential. At the same time that we have all of this talk about the urgent need to get every doctor’s office and hospital computerized coming out of one side of the collective mouths of the “reformers” we also hear out of the other side of the need to improve the patient’s experience when she goes to see her doctor or when she is in the ER. Those same bureaucrats and policy “experts” scampering through the legislative ant hills who extol the virtues of computerized efficiency also demand more time for patients from doctors and nurses, time spent one-on-one in providing medical care. Not too much time, though; these budget-watchers also bemoan the existence of so-called “concierge” practices, the ultimate expression of patient-centered medicine, because this model reduces the pool of doctors available to provide care.

The only conclusion that one can reach is that none of these EMR developers or policy developers has ever been a patient in an office or a hospital with an EMR!

The most important entity in the exam room or in a hospital room when an EMR is in use is the computer. The bigger the institution the more this is true. Mandatory questions must be asked in sequence and data entered in order. Imagine your doctor or her nurse as the best-educated data entry clerks in America and you get the idea. And it doesn’t matter whether it’s a computer and a keyboard or some sort of handheld gadget, the eyes of the doctor is on her screen, NOT her patient. The doctor has a relationship with her computer; the patient has a relationship with the back of the doctor’s head.

And you know what, it takes time to enter all that stuff. Much more time than it takes to jot down a couple of notes or a little data. Where will that time come from? Well, either it comes out of the time devoted to looking and listening, or it comes from decreasing the number of patients a doctor can see each day. Fewer employees necessary to run the computerized office? Really? What other customer service business has successfully reduced the number of people involved in providing that service to the satisfaction of its customers? It’s also really expensive to buy and implement and maintain an EMR. We’re talking about Billions of dollars up front and every year hence. Where will this money come from as doctors and hospitals struggle to remain afloat?

The EMR fails “in the wild”. It fails in PRACTICE to do either of it’s most important tasks; it neither increases efficiency nor does it improve the experience of the user. An EPIC fail (pun most definitely intended for you Epic users).

In the end the only winners in this EMR game at the present time are regulators and third-party payers. When we put all of the advantages of EMR in THEORY into PRACTICE the losers, once again, are patients and their doctors. With the present state of technology we will spend more money to buy systems that will decrease our efficiency and reduce the quality of experience that both our patients and doctors will have when healthcare is provided. And we haven’t even touched on the difficulties of maintaining the confidentiality of all of that information, or whether or not you can really pigeon-hole all of those messy, unquantifiable individual patients into tidy little treatment groups.

I have another picture in my mind, a picture of Yogi Berra in his doctor’s office. Yogi’s getting on in years you know. Probably has a couple of medical problems; probably taking a couple of medicines, too. Can’t you just see him, all ears and nose and those huge glasses underneath a vintage Yankees hat?

“If you could go back and change something, or have a “do-over”, what would you change in your life?”

Do you ever get asked this question? How do you respond? Do you look back and find unhappy episodes or periods of time, seeking to uncover the root cause of the upheaval in order to change that event or decision? Whether you view your life as a whole or your present circumstances as good or happy, do you ever indulge in this flight of fancy?

When I am asked this question I typically say something along the lines of: if you could tell me that I would be right here, right now, talking to you, with the same healthy and happy marriage and family, I would have been an art history major at Williams instead of a biology major. Not too many people are too very interested in the 5 genomic point mutations between prairie grass and maize (ZZZZZZ), but I’ll bet I could have discussed the differences between Monet and Manet a couple of times at cocktail parties and such. But even at that I still don’t think I’d change a thing.

On a flight home from Denver after visiting my son “The Heir” I sat next to a very nice man, Robin. We had about a dozen “one degree of separation” contacts to chat about, but we spent most of the time talking about how we had arrived in our lives at those two seats on that plane on that day. One of us seemingly sailing along, still on the ascent on the typical professional scoreboard, and one seemingly descended and becalmed.

Robin, in full sail, offered a regret. He regretted that he did not take 3 years off following college and prior to law school to live in his favorite city, Paris. I find this line of thought coming from a successful professional amazing. Always have. I find the choice of the word and sentiment “regret” to be puzzling, though.

In the truest sense of the word one would regret an act of omission or commission that causes harm to oneself or another. One can be sad that things may not have turned out as planned, or sad that an opportunity may have been missed, or even sad about an error or mistake that was unfortunate or embarrassing but did not result in any harm.

You see, for Robin to regret his decision to go directly on to law school would be to regret all that has come to him since that time, and I believe that this is a straight shot to a lifetime of unhappiness. Had Robin gone to Paris he would not have met his wife of some 30 years, would not be the father of the particular 3 successful daughters he “introduced” me to. Indeed, Robin and I would never have found ourselves sitting together, pleasantly whiling away the hours between Denver and Cleveburg.

Some years ago the White family decided to stay in Cleveburg when offered the opportunity to leave. It turned out to be a very bad economic decision, and to be quite honest, I am very sad about that. But as those of you who have read me these last couple of years know, my wife and I had a very sick child. Because we WERE in Cleveburg “Lovely Daughter” got exactly the right treatment from exactly the right people at exactly the right time. Don’t get me wrong–I really wish the economic realities here were different. The economic outcome has been dismal, with one inconvenience piled on top of another, and no way to ever truly recover.

But I don’t regret our decision for one minute, for each day I awaken I am still the father of a daughter. There is no way to know that I would still be able to say this if we had moved, if we had made a different decision and were, then and now, thriving economically. In truth, every decision we have ever made contributes in some way to where we are and what we have become today. Going back and teeing it up again might certainly create a better address today, but then again, perhaps not. I stayed in Cleveland and the little blond fluffball who reached up her arms–”Ina huggie!”–is still here, now reaching across at eye level for Daddy hugs.

I shared this story with Robin. I suggested that his wonderfully successful life probably afforded him the opportunity to live in Paris for a bit NOW, but this time with his wife of 30 years and visited by his own “Lovely Daughters”.